September 2019 - AUA Public Policy Council Update for MAS

From the Chair – Christopher M. Gonzalez, MD, MBA

I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on the election of a second urologist to Congress, our outreach to state medical societies, and a proposed pilot to expand access to telehealth services for low-income Americans and veterans.

Election Update: AUA Member Dr. Greg Murphy Wins Congressional Bid

Dr. Greg Murphy, a urologist in Greenville, NC, was elected to represent North Carolina’s 3rd Congressional District in a special election held September 10. He fills the seat vacated by Rep. Walter Jones, who passed away in February 2019. Dr. Murphy, who has represented State District 9 in the North Carolina General Assembly since 2015, will join Dr. Neal Dunn (R-FL-2) as the only urologists currently serving in the U.S. Congress.

Overall, there will now be 23 health care providers serving in the 116th Congress (18 physicians, 5 dentists). Having legislators that are familiar with the many challenges of practicing medicine and serving patients is critical to making real, substantive improvements to our nation’s health care delivery system.

As he enters Congress, the AUA looks forward to working with Dr. Murphy on issues that ensure access to needed urologic care and research.

Telehealth Services: AUA Responds to FCC Pilot

The Federal Communications Commission (FCC) proposed a three-year $100 million pilot within the Universal Service Fund to support telemedicine services for low-income Americans and veterans who do not have access to reliable broadband internet. Funding will be made available to providers to offset the cost of purchasing broadband internet to provide care to qualifying patients. The Commission expects that the pilot could benefit Americans that are responding to a wide breadth of health challenges, including diabetes management, opioid dependency, high risk pregnancies, pediatric heart disease, mental health conditions, and cancer. The AUA’s Telehealth Task Force reviewed the proposal and were encouraged by the opportunity to allow rural physicians the opportunity to provide care for Medicare patients through enhanced broadband internet access connectivity. The Task Force also provided data on the workforce shortage for urologists and how this proposal would enable increased patient access to urology specialty care.

The comment letter in response of the proposed rule is attached. Read more from the Proposed Rule on Promoting Telehealth for Low-Income Consumers.

State Advocacy Update: AUA Sends Introduction Letter to State Medical Societies

On August 28, the AUA sent a letter to every state medical society, as well as those in U.S. territories (i.e., Guam, Puerto Rico and Virgin Islands). This letter reintroduces the AUA, expresses the AUA’s ongoing interest in working together whenever possible, and highlights that the AUA is a resource on emerging provider/urologic issues within their state. AUA currently is in the process of scheduling in-person meetings and conference calls with several state medical societies to update them on our priorities and to strategize on ways to collaborate in the future. To date, we have already held calls with the medical societies of Washington DC, Vermont, Virginia and North Dakota.

For a copy of the letter sent to your specific state, or for more information on the AUA’s state advocacy efforts in your area, please contact the AUA’s State Advocacy Manager Andrea Oh at aoh@AUAnet.org.

National Insurers: The following insurance carriers provide national coverage.

Aetna

Aetna has revised the Urological Supplies medical policy with the following changes to criteria and coding:

  • Added medically necessary policy statement for ureteral stents for the following indications:
    • before surgery (e.g., gynecologic surgery, rectosigmoid surgery, aortoiliac surgery) to assist with intraoperative identification of the ureter;
    • following ureteroscopy for ureteral stone disease, ureteral stricture, or treatment of transitional cell carcinoma of the ureter or kidney;
    • management of ureteral obstruction due to nephrolithiasis, tumor, or retroperitoneal fibrosis;
    • following the creation of a ureteral anastomosis (i.e., ureteroureterostomy) for repair of ureteral injury (e.g., trauma, iatrogenic), kidney surgery (e.g., pyeloplasty), or renal transplant (i.e., neo-ureterostomy); or
    • Protection of a ureteral anastomosis prophylactically before extracorporeal shock wave lithotripsy.
  • Added experimental and investigational policy statement for ureteral stents for all other indications.
  • Added the following covered HCPCS codes for ureteral stents when criteria are met:
    • C1875 – Stent, coated/covered, without delivery system
    • C2617 – Stent, non-coronary, temporary, without delivery system
  • Added ICD-10 coding section for ureteral stents.
  • Added CPT codes related to ureteral stents, including but not limited to the following:
    • 50300 – Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral
    • 50340 – Recipient nephrectomy (separate procedure)
    • 50590 – Lithotripsy, extracorporeal shock wave
    • 50800 – Ureteroenterostomy, direct anastomosis of ureter to intestine
    • 52355 – Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor

Read the complete policy here.

Aetna has updated the Prior Authorization form for Provenge.  They have revised it with the following changes to questions and required information:

  • Added “will Provenge (sipuleucel-T) be used in combination with Xtandi (enzalutamide), Yervoy (ipilimumab) or Zytiga (abiraterone)?” as a question under the newly created “for all requests (clinical documentation required for all requests)” subsection.
  • Added “What is the absolute-value increase between the 2 values?” as a question under the “for initiation requests only” subsection.
  • Removed “will Provenge be used in combination with Xtandi (enzalutimide) or Zytiga (abiraterone)?” as a question under the “for initiation requests only” subsection.
  • Revised the answer options to question regarding progression found on bone scan from “1 or more new lesions” to “2 or more new lesions” under the “for initiation requests only” subsection.
  • Moved the following questions and required information under the newly created “for continuation requests (clinical documentation required for all requests)” subsection:
    • Has the patient previously received any doses of Provenge?
    • How many doses has the patient received?
    • Please indicate all dates of infusion(s)
  • Moved all existing questions under the newly created “for initiation requests only” subsection.
  • Added “mail order” as required information under the “dispensing provider/pharmacy” subsection.

Read the complete form here.

Cigna

Cigna is implementing a new reimbursement policy for Evaluation and Management services. Beginning on October 19, 2019 for claims processed on or after this date, Cigna will deny claims billed with CPT consultation codes as not being valid. Cigna considers a consultation is an E&M service provided at the request of another provider. Often consultations are used to obtain a recommendation for care of a specific condition or problem, or to determine whether a provider will accept responsibility for ongoing care of a patient. Claims can be resubmitted with the appropriate non-consultative E&M code that describes the service.

The affected CPT codes are as follows:

99241–Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99242–Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

99243–Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

99244–Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 

99245–Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family.

99251–Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99252–Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99253–Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 

99254–Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 

99255–Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit.

Read the complete update here.

Cigna has issued a new medical policy for Scrotal Ultrasound. Cigna has issued that a scrotal ultrasound will be considered medically necessary for an individual with ANY of the following indications:

  • acute scrotal pain or testicular torsion
  • acute scrotal trauma or injury
  • suspected infectious or inflammatory scrotal disease
  • scrotal neoplasm or mass
  • scrotal varices (varicocele)
  • hydrocele or spermatocele
  • nonpalpable testes
  • in evaluation of infertility

This medical policy will become effective October 21, 2019. For more information on this policy please read here.

United Healthcare

United Healthcare has revised the Split Surgical Package Payment Policy with the following changes to guidelines:

  • Added reimbursement guideline stating that more than one physician may furnish services included in the global surgical package, for which payment for the post-operative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care.
  • When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for higher payment.
  • Added reimbursement guideline for using modifiers 54 and 55, including that where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier (surgical care only; 54, post-operative management only; 55), and that for global surgery services billed with modifiers 54 or 55, the same CPT code must be billed.

Read the complete update here.

United Healthcare is implementing a new enhanced functionality in the Prior Authorization and Notification tool on Link that may provide improved response times for all lines of business. Beginning in October 2019, when providers submit a Prior Authorization request for certain services in the Link Prior Authorization and Notification tool, providers will be prompted to provide clinical information and may receive improved response times on prior authorizations within the site. This is part of the efforts to help simplify administrative responsibility and the prior authorization process. By gathering pertinent clinical information with the initial submission, United Healthcare can use the information to evaluate requests, allowing for quicker decisions, and improve the efficiency of the prior authorization process. The functionality will be released for many service categories requiring prior authorization throughout the coming months.

For more specific information please access the new Technology Enhancement Topic found in the Interactive Guide for the Prior Authorization and Notification Tool which includes:

  • What you can expect in the Prior Authorization and Notification tool
  • Impacted service categories
  • Pertinent clinical information necessary for submission
  • What is the same and what is different
  • Frequently Asked Questions.

Read the complete update here.

United Healthcare Community Plan

Effective October 1, Optum, an affiliate company of United Healthcare, will begin managing all prior authorization requests for outpatient injectable chemotherapy and related cancer therapies for United Healthcare Community Plan members in New Jersey. Any active prior authorizations requested through the former process will remain in place.

Prior Authorization for Outpatient Injectable Chemotherapy and Related Cancer Therapies Prior authorization will be required for the following:

  • Chemotherapy and biologic therapy injectable drugs:
    • J9000-J9999
    • Leucovorin (J0640),
    • Levoleucovorin (J0641)
  • Chemotherapy and biologic therapy injectable drugs that have a Q code
  • Chemotherapy and biologic therapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code
  • Denosumab (Brand names Xgeva® and Prolia®): J0897

Prior authorization will be required when adding a new injectable chemotherapy drug or cancer therapy to an existing regimen.

Read the complete update here.

United Healthcare Community Plan has updated the Incontinence Supplies policy with the following revisions:

  • Updated state exceptions to include the following quantity limits for North Carolina:
    • 192 per month for HCPCS codes:
      • T4521-T4524–Adult sized disposable incontinence products
      • T4529-T4530- Pediatric sized disposable incontinence products
      • T4533- Youth sized disposable incontinence products
      • T4544- Adult sized disposable incontinence products, protective underwear/ pull on
    • 200 per month for HCPCS codes:
      • T4525-T4528-–Adult sized disposable incontinence products
      • T4531-T4532–Pediatric sized disposable incontinence products
      • T4534–Youth sized disposable incontinence products
      • T4543–Adult sized disposable incontinence products, protective underwear/ pull on
    • 150 per month for HCPCS code:
      • A4554–Disposable under-pads, all

Read the complete policy here.

Local and Regional Updates

The following are updates in your Section. Please contact AUA Executive Vice President Kathleen Zwarick at kzwarick@AUAnet.org for more information on any of these issues.

A majority of state legislatures have adjourned for the remainder of 2019. Regardless, the AUA will continue to monitor state legislative, regulatory, and insurance issues that affect urology.

New Jersey

The following insurance update covers Pennsylvania, New Jersey and Delaware.

AmeriHealth Caritas VIP Care Plus has revised its Enhanced Cystoscopy for Bladder cancer medical policy. The use of photodynamic diagnosis may be considered medically necessary when criteria are met.

  • Must be performed after or concurrent with white light cystoscopy.
  • History of invasive bladder cancer with treatment initiated at the first 3-month cystoscopy.
  • Used to guide transurethral resection.

Read the complete policy here.

Horizon Blue Cross Blue Shield New Jersey has revised the Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer medical policy with the following criteria changes for 4Kscore testing and ConfirmMDx testing:

  • Expanded list of applicable indicators denoting higher risk for prostate cancer to include the following:
    • family history of two or more first-degree relatives with prostate cancer diagnosed at any age;
  • PSA level of greater than 10 ng/ml;
  • PSA level increase of greater than 0.35 ng/ml/year if PSA level less than or equal to 10 ng/ml;
  • And/or PSA doubling time of less than 3 years, when initial PSA level is greater than or equal to 4 ng/ml and other causes of rising PSA (i.e., infection, inflammation) have been ruled out for individuals whose PSA doubling occurred in less than 2 years.

Read the complete update here.

Pennsylvania
HealthPartners has revised the Denosumab (Prolia and Xgeva) with the following changes to criteria:

  • Revised initial authorizations for Prolia and Xgeva to add requirement that Prolia and Xgeva must be prescribed within the FDA-approved dosing regimen;
  • Added criterion that initial authorizations will be approved for 12 months.
  • Revised reauthorizations for Prolia and Xgeva to add requirement that that member has been seen in the past 12 months and that documentation proves that the member has had clinical improvements from treatment with Prolia and Xgeva.
  • Revised initial authorizations for Xgeva to add requirement that it be used in the treatment of adults and skeletally mature adolescents with giant cell tumor of bone that is unresectable or where surgical resection is likely to result in severe morbidity.
  • Revised coverage section to add statement that Prolia and Xgeva are medically necessary for the indications listed when all criteria are met per the member’s plan documents.

Read the complete policy here.

Capital Blue Cross has revised its policy statement for Provenge.  The revised policy statement states that Provenge therapy may be considered medically necessary in the treatment of asymptomatic or minimally symptomatic metastatic castrate-resistant (hormone-refractory) prostate cancer.

The following information are other revisions to this policy:

  • Removed additional requirements previously denoting metastatic androgen-independent (castration-resistant) prostate cancer; life expectancy of at least six months; serum prostate specific antigen (PSA) greater than or equal to 5.0 mg/dl; castrate level of testosterone less than 50 mg/dl; and negative serology for HIV 1 & 2, Human T-cell lymphotropic virus type 1 (HTLV1), and Hepatitis B and C.
  • Removed statement specifying that Provenge therapy is considered investigational in all other situations, including but not limited to treatment of hormone-responsive prostate cancer, treatment of those with moderate to severe symptomatic metastatic prostate cancer, and those with visceral (liver, lung or brain) metastases.
  • Removed statement specifying that administration of Provenge beyond the recommended course of therapy (three infusions) is considered not medically necessary.

Read the complete policy here. 

Capital Blue Cross Blue Shield has revised the Urinary Tumor Markers for Bladder Cancer with the following changes to criteria and coding:

  • Revised criterion to specify that urinary biomarkers (bladder tumor antigen (BTA) test, nuclear matrix protein (NMP22) test, or fluorescence in situ hybridization (FISH) UroVysion bladder cancer test) meet coverage criteria as an adjunct in the monitoring of “high-risk, non-muscle invasive” bladder cancer.
  • Added the following CPT codes:
    • 0012M – Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma
    • 0013M – Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma
  • Removed the following CPT codes:
    • 88271 – Molecular cytogenetics, DNA probe, each (e.g., FISH)
    • 88299 – Unlisted cytogenetic study
    • 88365 – In situ hybridization (e.g., FISH), per specimen; initial single probe stain procedure

Read the complete policy here.

HR 464 – Urological Procedure Awareness
On September 5, Representative Rosemary Brown (R) introduced HR 464. This measure declares September 2019 as “Polystystic Kidney Disease Awareness Month” in Pennsylvania.

This measure has been referred to the House Health Committee. The resolution is available here: 9/5/2019 Version

ICYMI: Updates from the AUA Policy & Advocacy Brief blog 

Bladder Health: PCORI to Join AUA/UCF in Promoting Bladder Health Efforts

The AUA and UCF have been working with the Patient-Centered Outcomes Research Institute (PCORI) on collaboration efforts to promote Bladder Health Month in November. The collaboration includes PCORI attending and presenting at the upcoming Bladder Health Alliance (BHA) Roundtable meeting taking place on October 2 in Washington, DC and promoting new research findings related to bladder health throughout November.

Kimberly Bailey, Senior Program Officer for the Clinical Effectiveness and Decision Sciences program at PCORI, will review the role of PCORI in the research funding landscape, focusing on patient and stakeholder engagement in the clinical effectiveness research that PCORI funds during the BHA roundtable meeting. This presentation is part of a full-day program that hosts representatives from more than 25 patient and physician advocacy organizations who will convene and discuss issues impacting patients living with conditions that impact bladder health and information on the latest research taking place to improve patient care. Key discussion items include how bathroom policies and procedures impact patients, bladder health education initiatives, November’s Bladder Health Month campaign, and effective marking approaches to raise awareness about bladder health conditions. You can follow and join the day’s conversation on Twitter by following hashtag #bladdersmatter. 

Patient Advocacy: AUA Presents at Prostate Cancer Disparity Summit

On September 12, the AUA participated in the 15th Annual Prostate Cancer Disparity Summit, hosted by the Prostate Health Education Network (PHEN). During the event, the AUA presented on its advocacy activities to improve patient access to prostate cancer screening and research. Topics included the AUA’s work on the USPSTF Transparency and Accountability Act, as well as the 2019 AUA Summit “ask” to include the need for increased research efforts towards better understanding of prostate cancer among African American men and those in other high-risk populations. To watch the recorded stream of the event, please visit PHEN’s Facebook page at facebook.com/ProstateHealthEducationNetwork.

Research Advocacy: AUA Meets with Department of Defense Kidney Cancer Research Program

In collaboration with the Kidney Cancer Coalition, the AUA met with Theresa Miller, Program Manager for the Kidney Cancer Research Program (KCRP) that is supported by the Department of Defense (DoD) Congressionally Directed Medical Research Program (CDMRP). The meeting provided an opportunity to share information regarding current and upcoming program announcements and how to ensure the kidney cancer community stays apprised of information related to the KCRP solicitation and application process. The AUA will continue providing outreach to the kidney cancer advocacy community to ensure researchers are encouraged to apply for funding and that they are aware of upcoming opportunities.

As background, the KCRP was established in Fiscal Year (FY) 2017 when Congress directed $10 million to the program and received $30 million for FY 2020. The program focuses on prevention, detection, treatment, and the long-term effects of treatment for kidney cancer for service members, veterans, their families, and the American public. Learn more here.

2020 Gallagher Scholar: AUA Accepting Applications

The AUA is now accepting applications for the 2020 Gallagher Health Policy Scholar program. Applicants must be AUA member urologists who have demonstrated a commitment to or have a keen interest in the field of health policy and who are dedicated to advancing urology’s health policy agenda. Previous Gallagher Scholars are now among some of the AUA’s top health policy leaders, and attribute participation in this program as a key step in making the transition into leadership roles. Learn more about the program and how to apply.